Patient-practitioner communication has been a focus in medicine for several decades.1 Good communication between doctors and patients has been shown to be an important element of care, with numerous benefits for either patients, doctors, or both.1–6 Conversely, most patient complaints result from poor communication with the medical provider,2,7–9 and research indicates numerous and common problems in patient-provider communication that adversely affect patient outcomes.7,10
Although there is no single universally accepted definition, there are general concepts that describe good communication. Communication is an interactive process that holds meaning for all people involved, with meaning derived from the context and environment in which the interaction takes place.11 There are multiple aspects to the communication process: some are visible and audible, while others are invisible and silent.11 All aspects of the communication process have culturally defined meanings that vary for people in different contexts and environments.11 Thus, for effective communication, it is essential that persons engaged in the communication process have mutually defined meanings of all aspects of the process (verbal and nonverbal). Trust between the people engaged in the process is also a key element of good communication. Trust is required to both convey and receive a clear message with meaning.
The process of good communication is often considered an art form.5,12 Applying knowledge about good communication into an effective personal style that creates benefits for both patient and practitioner constitutes the art of good communication.5 Implementing good communication skills in patient encounters takes practice, finesse, and motivation, in part, because good clinical communication is intentional and different from communication between family and friends.13
As part of both patient-centered care and evidence-based practice models, it is important to know what the patient wants and what his or her goals are for treatment (i.e., patient values and preferences integrated with clinical expertise and best available research evidence).14 For example, good clinical communication is particularly important in orthotics and prosthetics to elicit patient goals and to ensure that patients understand how to safely and effectively use the devices provided and are satisfied with them. The American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) Scope of Practice document15 specifically lists communication skills as a requirement for professional certification, further underscoring the importance of developing good communication skills for use in orthotic and prosthetic clinical care.
However, what constitutes good patient-practitioner communication has received limited attention within orthotics and prosthetics research. Only one study regarding communication between patients and prosthetists was found at the time of this review.16 The study used data collected from online discussion groups where persons with lower-limb amputation communicated with each other about issues related to their prosthetic care, including communication and relational problems with prosthetists. The results indicated a need to improve communication between prosthetists and patients. Murray16 reported that prosthetists need to share more information, communicate in a more understandable language, and provide increased opportunities for patients to make choices as part of the prosthesis prescription process.
Fortunately, there are many similarities between a medical encounter and an orthotic/prosthetic encounter with regards to patient assessment, formulation of a treatment plan, plan implementation, education, and follow-up. Both the medical and orthotic/prosthetic disciplines use patient-centered care and evidence-based practice models. Thus, it may be possible to apply information from the medical literature, where there is a relative wealth of research on good communication, to the field of orthotics and prosthetics.
Engaging in good clinical communication requires effort, time, and energy from the practitioner to develop knowledge of the aspects of good communication, convert this knowledge into action, and reflect on communication interactions to further develop the art of good communication. Given the many demands, tasks, and obligations of clinical practice, motivation is important when considering a behavioral change such as developing good clinical communication skills. Hence, we reviewed the literature regarding good communication between doctors and patients to identify potential benefits for orthotists and prosthetists that may motivate them to develop and use good communication in their clinical practice.
A literature search was performed using PubMed, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, and Google Scholar, as well as hand searching the references of included articles. Key phrases, such as “benefits of good communication,” “communication in medicine,” “benefits to doctors of good communication,” “importance of communication in medicine,” and “communication in patient-centered care,” were used in the search. Searches were restricted to the English language. The titles and abstracts of the retrieved articles were examined to determine if they mentioned practitioner benefits of good communication. If they did, full articles were retrieved.
Articles were included in the review if they identified benefits (to providers) from other medical disciplines. Benefits were defined as a gain or advantage to the practitioner resulting from good communication. If an article did not mention any benefit to the practitioner, it was excluded. These benefits of good communication were then extracted from the articles using a data extraction table designed to organize and categorize the benefits to the provider.
The benefits identified by this review were then examined, and relevance was considered in the context of a typical orthotic and prosthetic practitioner/patient encounter. Practitioner/patient encounters were considered as those that follow the practice framework delineated by the ABC Scope of Practice.15 In addition, other orthotic and prosthetic clinical and professional factors, such as prescription requirements from doctors, referrals from doctors and/or therapists, hospital calls, practice settings, documentation requirements, medical justification requirements, time constraints, outcome measures, patient satisfaction surveys, accreditation requirements, and coding and billing, were considered. The benefits to medical personnel were summarized as beneficial themes that were considered potentially relevant to orthotists and prosthetists.
A total of 71 articles were found that met the inclusion criteria. From these articles, 17 benefits to medical practitioners of using good patient-practitioner communication were identified (Table 1). These benefits were categorized into five beneficial themes that were considered potentially relevant to orthotists and prosthetists. Although the benefits from other medical disciplines were not necessarily exclusive to one of the five beneficial themes, to facilitate discussion, each benefit was listed within only one beneficial theme category.
The overall goal of this project was to provide information regarding potential benefits to practitioners of good patient-practitioner communication as motivation for orthotists and prosthetists to develop and use good communication in clinical practice. Our literature review identified 17 benefits to medical providers of good patient-practitioner communication, which, when considered within the context of a typical orthotic and prosthetic patient encounter, resulted in five beneficial themes potentially relevant to orthotists and prosthetists. The sequential listing of beneficial themes is not indicative of any value or significance. The clinical scenarios presented in Table 2 help illustrate some of these beneficial themes in the context of prosthetics and orthotics practice.
POTENTIAL BENEFICIAL THEME 1: LESSENS THE RISK OF LITIGATION
In any practice environment, whether medicine or orthotics and prosthetics, litigation is a concern. Lawsuits are costly to any practice17 in terms of time, reputation, and financial resources regardless of the verdict. Studies reveal that medical providers who use good communication and maintain good relationships with their patients are sued less.2,3,5,7,17–37 The following are specific claims from the literature:
- Greater than 80% of all lawsuits filed against health care providers cite poor communication as the primary reason.2
- Patients often identify lack of empathy and poor communication as contributing aspects in pursuing litigation against their physician.37
- Surgeons with a dominant (deep, loud, fast, unaccented, and articulated) tone of voice are sued more often than surgeons with a less dominant tone of voice.22
- Most patients want their doctor to acknowledge minor errors or mistakes. Lack of acknowledgment of moderate to severe errors leads to the filing of lawsuits.17
- Breakdowns in doctor-patient relationships are a stimulus for litigation.17
It is clear from these examples that a large element of risk management hinges on good patient relationships and communication. People are less likely to consider suing those they trust and with whom they have a good relationship. Risk is further mitigated by patients knowing, being able to recall, and adhering to treatment protocols: lessening a patient's chance of adverse outcomes from treatment. By following the prescribed treatment protocol, patients minimize their risk of harm by problem prevention, taking action at early signs of problems, and taking care of themselves and their devices. As illustrated in the first clinical scenario in Table 2, prosthesis and orthosis users must be aware of potential threats to proper device function and potential damage to a device related to both environment and pattern of use. Risk management is based, in part, on practitioners knowing the types of activities a patient may engage in and patients knowing and understanding the risks of device use in those activities. With such knowledge, there are fewer surprises when complications arise because the patient is less likely to feel uninformed if he or she is aware of the likely risks. When patients have reasonable expectations of the intervention, the risk of litigation is reduced.
POTENTIAL BENEFICIAL THEME 2: MAKES EFFICIENT AND EFFECTIVE USE OF APPOINTMENT TIME
Time is of the essence in both medical and orthotic and prosthetic clinical practice. A common misconception is that good communication takes too much time in the clinical encounter and appointments run over their allotted time. However, medical research demonstrates that using good communication does not contribute to longer appointments.10,18,21,25,29,30,34,37,55–58 Rather, good communication elicits important clinical information from patients that makes more efficient use of the appointment time.12 The perception of time is interesting as it is shaped not by the actual minutes but rather the quality of those minutes.37 Hence, it is not the quantity of time that creates good communication and a relationship with a patient, but rather the quality of time and interaction.
Doctors who used good communication reported that it was easier to manage the time of an appointment and meaningfully direct the conversation.4 They avoided failing to discuss or address the issues important to the patient before the appointment came to a close.4 Consider that studies have shown that in 69% of visits, physicians interrupt patients during their opening statement after a mean of just 13 to 18 seconds.12 Such interruptions are ultimately costly because important patient concerns may not be expressed before the clinician begins to close the encounter.12
According to Murray,16 many prosthetic patient issues and concerns are directly related to communication with the prosthetist. For example, prosthetists are trained to instantly recognize what prosthetic adjustments are needed in response to a patient saying, “I feel like I'm walking uphill…” However, patients do not understand the biomechanical implications of such a phrase. If, as in the second clinical scenario in Table 2, prosthetists make a quick adjustment before the patient has finished speaking, the patient may feel unheard and may question if anything was done to address the issue he or she was attempting to describe. This may create doubt in the prosthetist's technical ability simply based on communication, when in fact, an appropriate adjustment may have been made.
The amount of time a patient talks at the beginning of an appointment if uninterrupted is less than 2 minutes.47 The benefits of allowing time at the start of an appointment to gather a patient's concerns include the following: 1) it gives the clinician more complete information to plan the remainder of the encounter, 2) it focuses the encounter on the priorities the patient assigns to his or her concerns, and 3) it identifies clinical concerns that may not have been part of the reason for the visit. Researchers have found that a patient's first stated concern is not necessarily his or her chief concern.10 This issue is illustrated in the third clinical scenario in Table 2.
Patient disclosure of information is important in the use of evidence-based practice. Without good communication, it becomes impossible to identify an intervention that will be beneficial and acceptable to the patient. If concerns and desires are not heard and addressed, the patient may not accept the device. This may create the need for additional follow-up appointments at which the underlying issue is never resolved and the cycle of follow-up visits continues without resolution or the patient fails to follow up altogether. As illustrated in the second clinical scenario in Table 2, avoidable follow-up appointments become unnecessarily costly in terms of resources for both the patient and clinician. This is particularly problematic in orthotics and prosthetics where reimbursement is based on items delivered or repaired, with provision of education, training, adjustments, and follow-up care included in the one-time cost of the device. Good communication helps ensure that the practitioner identifies and addresses all the patient's issues, reducing the need for additional follow-up appointments.
POTENTIAL BENEFICIAL THEME 3: IMPROVES PATIENT OUTCOMES
The orthotic and prosthetic profession relies on referrals and prescriptions from doctors who are also vested in good outcomes and patient satisfaction. For example, the surgeon who performs an amputation wants the patient to have the best outcome possible; however, that outcome depends, in part, on the care and treatment provided by the prosthetist. Hence, if the patient is unsatisfied with the prosthesis because it hurts to walk, he or she may also be unsatisfied with the operation.
Good communication has positive effects on health outcomes.12 Street et al.38 explains that outcomes of good communication include patient understanding, trust, and clinician-patient agreement, which in turn affect intermediate outcomes such as adherence and self-care skills, and ultimately health and well-being.
Good communication is an integral part of achieving a safe and realistic outcome. For example, it is important for orthotic and prosthetic patients to understand how to safely and effectively use their device as illustrated in the first clinical scenario in Table 2. This requires they be able to recall visit information accurately; without this understanding, adverse events are more likely to occur. If there is no perceived benefit from the device, it is likely to go unused by the patient. If a device is unused, the patient will not derive a benefit and will no longer need the services of an orthotist or prosthetist because an unused item never needs repair or replacement.
POTENTIAL BENEFICIAL THEME 4: IMPROVES PATIENT SATISFACTION AND INCREASES REFERRALS
Maintaining a consistent stream of referrals is an important part of an orthotic and prosthetic practice. Research suggests good communication influences a patient's loyalty to a provider10; if patients are satisfied with the care they receive from practitioners, they are more likely to refer family and friends.10 Conversely, failure of physicians to adequately communicate with patients is a major reason patients change physician practices.12 Orthotic and prosthetic care is a consumer's market: it is relatively easy for patients to change providers at any given time. Murray's16 research indicates that 32% of patients change their prosthetist due to dissatisfaction. Because it is challenging to attract new referrals, it is important to retain each patient for whom care is provided.
Adjusting to a disability or amputation takes time and is emotionally taxing, which can affect patient satisfaction. Maguire and Pitceathly48 emphasize that when doctors use good communication skills effectively, patients are better psychologically adjusted and more satisfied with their care. Patient satisfaction warrants attention because it plays a large role in the definition of quality of care held by patients.2 It is through good communication that patients receive the necessary information, understanding, feedback, and treatment options that result in satisfaction.7,48 When patients are satisfied with their care, they are more likely to refer family and friends.
POTENTIAL BENEFICIAL THEME 5: IMPROVES PRACTITIONER JOB SATISFACTION
Providing care to patients is often a complicated and taxing endeavor. Studies often recognize the impact on the patient of poor communication, but ineffective or poor communication also has adverse effects on the doctor that are often overlooked.1 Studies demonstrate good communication has positive effects on the well-being and job satisfaction of the doctor.1–5,9,10,12,21,24,28,30,31,33,37,48,49,57,69,73 Warnecke5 reported that doctors who took an intensive course in mindful communication improved both patient outcomes and personal well-being.
Some patients may be perceived as unreasonable by the care provider. People, including medical providers, usually prefer to work with people who are not viewed as unreasonable. The research of Veldhuijzen et al.4 demonstrated that when doctors used good communication skills and techniques, they came to see fewer patients as unreasonable.
GOOD COMMUNICATION FACILITATES ADHERENCE TO THE ABC SCOPE OF PRACTICE AND CODE OF PROFESSIONAL RESPONSIBILITY
The ABC Scope of Practice document clearly explains the responsibilities of orthotic and prosthetic practitioners. The document states that certified orthotists/prosthetists are obligated to conform to professional responsibilities that assure the welfare of the patient and integrity of the profession.15 Fulfilling this professional obligation requires good communication skills to elicit information from the patient about his or her desires. In addition, evidence-based practice requires that practitioners know the patient's goals for treatment, not just their own. This information is only attainable through good communication with patients. Hence, good communication allows practitioners to adhere to the code of ethics and scope of practice for which they are certified.
LIMITATIONS AND FUTURE RESEARCH DIRECTIONS
While this review is an important stepping-stone to understanding the potential benefits of good communication to orthotists and prosthetists, there are limitations. For example, given the simple phrase-based search method, it is possible that relevant articles were missed during the search. Having just one reviewer search and examine the literature increases the potential for bias. In addition, the reviewer was a student in orthotics and prosthetics who had not yet worked as a certified orthotist or prosthetist. While this inexperience made relating benefits from the medical literature to the orthotic and prosthetic clinical setting challenging, it was tempered to some extent by the clinical and professional experience of the other authors.
In the future, better methods of analyzing practitioner communication skills need to be developed, so that practitioners can identify areas specific to their communication that need improvement. Development of best practices for good patient-practitioner communication in orthotics and prosthetics is also needed. Finally, research is needed to develop communication training opportunities for orthotists and prosthetists.
This review identified 17 benefits to the medical provider of using good patient-practitioner communication that were categorized into five beneficial themes potentially relevant to orthotists and prosthetists. Highlighting these benefits may help motivate prosthetists and orthotists to reflect on their communication skills, develop new communication knowledge, and convert this knowledge into action to develop their own art of good communication in orthotics and prosthetics clinical practice.
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